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General NPI Number Information
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NPI Number | 1912302845
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Entity Type | Organization
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Legal Business Name | MIND BODY WELLNESS LLC
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 1753 E BROADWAY RD STE 101-460
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City | TEMPE
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State | AZ
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Zip | 85282-2081
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Country | US
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Telephone | 480-345-5420
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Fax |
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Provider Business Mailing Address
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Address Line | 1753 E BROADWAY RD STE 101-460
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City | TEMPE
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State | AZ
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Zip | 85282-2081
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROVIDER
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Name | BAHAR GOLESTAN
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Credential | MD
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Telephone | 480-345-5420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 42214
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License Number State | AZ
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